Haematology

This chapter describes the anaesthetic management of the patient with a haematological disorder. Topics covered include anaemia; sickle-cell disease; porphyria; coagulation disorders; haemophilia and related disorders; platelet disorders and hypercoagulability syndromes. For each topic, pre-operative investigation and optimisation, treatment, and anaesthetic management are described. There is detailed discussion about the perioperative management of the patient taking a drug which affects the coagulation system, including anticoagulants, antiplatelet drugs, fibrinolytic and antifibrinolytic drugs. Coagulation tests are discussed in detail, and the haematological management of the bleeding patient is described.

449 Burden of Epistaxis - Room for Improvement?

Aim We conducted an audit at a large tertiary hospital of the measures and information given to patients admitted with Epistaxis. The aim of this audit was to identify factors for prolonged inpatient admissions and elucidate the extent of patient suitable information provided. Method A retrospective audit was conducted collecting data over two months on all patients admitted with epistaxis. Data was collected on demographics, co-morbidities, length of stay, discussions with other specialities and the extent (verbal/written) of information given to patients with regard to management of epistaxis in the community and how to reduce the risk of further episodes of epistaxis. Results Sixty patients were identified with an average age of 68 years. The patients were inpatients for an average of 41 hours. 10% had a form of haematological disorder, 40% were on warfarin/DOAC and 45% had hypertension. 40% had neither verbal nor written information given about either management or reducing risk. 10% had written information about both. 8% were re-admitted within 30 days of discharge and 17% had previously been admitted with epistaxis in the last 6 months. Conclusions Epistaxis is a common inpatient admission in ENT with a significant bed burden on the department. A significant proportion of patients are co-morbid and thus easily understandable trust guidelines on management of epistaxis on warfarin/doac should be available to reduce length of stay. The low proportion of patients provided with information to help self-care is significant and is likely to play an important role in the re-admission rates.

Ibrutinib in patients with atrial fibrillation – the challenge of thromboembolic prophylaxis

Ibrutinib is a novel drug used in haematological malignancies. Its use is associated with an increased risk of atrial fibrillation (AF), which, in turn, exposes patients to embolic risk, including stroke. Reducing this risk requires anticoagulant therapy which is a matter of concern in the context of the increased bleeding risk of patients with haematological malignancies. In this context the presence of thrombocytopenia related to haematological disorder, ibrutinib-anticoagulants and ibrutinib-platelets interactions contribute to the amplification of the problem. The correct assessment of the thrombosis vs. haemorrhage balance represents a significant challenge for the clinician. In this paper we discuss practical issues related to anticoagulation in patients treated with ibrutinib and incident AF.

Referral Pattern and Haematological Disorders in a Tertiary Hospital

This study aimed to determine the pattern of referrals and haematological disorders at Benue State University Teaching Hospital. This was a retrospective study of records of a total of 222 adults and Paediatric patients suspected to have haematological disorders, seen and referred from different clinics and wards within and outside the study facility to the Haematologists for evaluation between June 2012 to July 2019 inclusive. These patients were clerked by the Haematologists, peripheral blood samples were taken for full blood count, red cell indices, reticulocyte count and peripheral blood film examination. Bone Marrow Aspiration was done on all the patients and the slides examined. Where indicated, further flowcytometry was done for complete diagnosis. Of the 222 referred, 127 (57.2%) were males while 95(42.8%) were females, with M:F ratio of 1.3:1. The age range of patients was 3 to 95 years with median age of 36.5 years. Those in the age group of 16-35 years constituted the majority 81(36.5%), while the least 5(2.3%) referred cases were in the age group of 76 years and above. The highest referral to the Haematologists was 40(18%) in 2015 and 2018 each. The bulk of referrals to the Haematologist was from Medicine 103(46.4%), followed by referrals from General Outpatient Department (GOPD) 29(13.1%) and then Paediatrics 27(12.2%), the least was from Ear Nose and Throat (ENT). The main indication for referral was Unexplained Anaemia 68(30.6%), followed by Splenomegaly 26(11.7%). One hundred and eighty (81.1%) of the total referred cases had at least an established haematological disorder. The most common haematological disorder established from the total referred cases was Combined Iron Deficiency Anaemia and Megaloblastic Anaemia (IDA/MA) 52(23.4%). This was followed by Chronic Lymphocytic Leukaemia (CLL) 23(10.4%). In conclusion, referrals from other physicians to the Haematologists have very high likelihood of haematological disorder. We recommend that attending Haematologists treat all referred cases with very high index of suspicion so as not to miss a potentially life threatening haematological disorder.

Introduction to haematology

Haematology is the study of the composition, function, and diseases of the blood. The approach to a patient suspected of having a haematological disorder begins with taking a history (particularly noting fatigue, weight loss, fever, and history of bleeding) and performing a clinical examination (looking for signs of anaemia, infection, bleeding, and signs of cellular infiltration causing splenomegaly and/or lymphadenopathy). Key investigations include a full blood count, a blood film, and (in selected cases) examination of the bone marrow. Further diagnostic tests now routinely performed on blood and marrow samples include immunophenotyping and cytogenetic and molecular analysis. Mutational signatures may be diagnostically useful and potentially define treatment, keeping haematology in the vanguard of advances in modern medicine.

Haematology: drugs, tests, and disorders

This chapter describes the anaesthetic management of the patient with a haematological disorder. Topics covered include anaemia, sickle-cell disease, porphyria, coagulation disorders, haemophilia and related disorders, platelet disorders, and hypercoagulability syndromes. For each topic, preoperative investigation and optimization, treatment, and anaesthetic management are described. There is detailed discussion about the perioperative management of the patient taking a drug which affects the coagulation system, including anticoagulants, antiplatelet drugs, and fibrinolytic and antifibrinolytic drugs. Coagulation tests are discussed in detail, and the haematological management of the bleeding patient is described.